Presented By :

Dr. SUBHASIS ROY , CONSULTANT, SISU SANJIBAN HOSPITAL ,

SALT LAKE , KOLKATA

THE HISTORY

1774 – J. Priestly produced O2 – “Dephlogisticated Air”

1776 – A. L. Lavoisier termed this vital air – OXYGEN

Late 1800 – Bonnaire gave O2 to preterm “Blue Baby”

with success .

1907 – A. Lane invented NASAL CATHETER

1919 – L. Hill developed O2 TENT.

1920 - O2 therapy became routine for “SICK NEW BORN”

O2 THERAPY IN NEONATE VS OLDER CHILDREN

 

 In Neonate – 

O2 reserve less

O2 requirement / kg. higher.

Small change in Fi O2 – large change in Pa O2

Unrestricted O2 therapy – produce pulmonary / extra

pulmonary hazards.

 MORE CAUTION REQUIRED IN NEONATAL O2 THERAPY

NEW BORN RESUSCITATION – HOW IMPORTANT O2 IS

CURRENT RECOMMENDATION – 100% O2 IN NRPBUT

A GROWING OPINION THAT RA CAN BE USED IN PLACE OF O2

Approx 100 million babies born annually, globally

- 10 million need resus ! . Cochrane review :

RAR group shorter time to first breath and first cry.RAR group – only 25% required 100% backup O2 facility.RAR group – Marginally lower overall mortality.No evidence of HARM in using RA

BUTINSUFFICIENT DATA TO RECOMMEND RA OVER 100% O2

NEW BORN RESUS. IS A SCIENTIFIC PROTOCOL BUT MORE AN “ART”THAN A “SCIENCE” IN DEVELOPING COUNTRIES WITH RESOURCECONSTRAINTS. NOT TO PANIC IF O2 SUPPLY IN LABOUR ROOM IS RESTRICTED OR NOT AVAILABLE.

ASSESSMENT OF NEED OF O2 THERAPY

 DURING AND JUST AFTER RESUSCITATION IN NEWBORN

Only clinical – Cyanosis

Heart rate i.e bradycardia

Resp effort

Muscle tone

Response to stimuli

 LATER PART OF THE NEW BORN LIFE

 Clinical – Cyanosis

  Heart rate

  Pattern of breathing i.e. apnoea/Periodic breathing

Monitoring - ABG – PaO2 < 50 mm.Hg.

  Trans cutaneous oxygen monitoring

  Pulse oximetry - SpO2 < 85 %

MODES OF OXYGEN DELIVERY

  SOURCE

O2 cylinder

  O2 concentrator - max 5 – 8 lit / min. of 90 – 92% O2

         Pipeline - Cheapest

 

MODES OF OXYGEN DELIVERY…

DELIVERY DEVICE

LOW FLOW DEVICE

  Nasal Canula – Max flow 2 – 3 lts./min. in new born.

Nasopharyngeal Catheter

Insert a length – Alae nasai to Tragus

Check for blockage with mucus plug

FiO2 difficult to measure/control

Better if changed 24 hrly.

Not more than 3 lit. / min. O2 in new born

Every lit. of O2 - FiO2 by 4

MODES OF OXYGEN DELIVERY…

HIGH FLOW DEVICE

  Mask

mask with 5 lit / min O2 can give 40 – 60% O2

require a minimum O2 flow to prevent rebreathing of CO2

  Enclosure system

O2 hood - > 7 lit./ min of 100% O2 required initially to wash out CO2

  FiO2 can be 0.21 – 1.

O2 given < 4 lit. min. can be managed without humidifier.

WHAT TO EXPECT FROM ADEQUATE OXYGEN THERAPY

 A. Clinical Monitoring:

  No cyanosis

No apnoea or periodic breathing

  Stable heart rate

 B. Non Invasive Monitoring:

Pulse Oximetry

  Alarm set 85 – 96% SpO2

Target range 88 – 95% SpO2 Except PPHN

SpO2 >97%

Unable to detect hyperoxia reliably

Plenty of other limitation

WHAT TO EXPECT FROM ADEQUATE OXYGEN THERAPY..

Trans centaneous O2 monitoring

  Not accurate in term babies with thick skin

Not used in prematures < 27 wks.

Heat related problems – skin heated to 44oc

 C. Invasive monitoring

  ABG

Gold standard

8 – 12 hourly – may be required

PaO2 – 50 – 80 mm Hg.

  PaO2 – 100 – 120 mm Hg acceptable in PPHN

NON RESPONDERS TO OXYGEN THERAPY

CCHD - COMMONEST LARGE INTRAPULMONARY SHUNT - UNCOMMONMETHAEMOGLOBINAEMIA - RARE

HYPEROXIA TEST

FiO2 0.21 FiO2 1.0 x 10 min

NORMAL 70 (95) >200(100)

CCHD <40 (<75) <70(<85)

PULMONARY 50 (85) >150(100)

MARKERS OF O2 MONITORING

PiO2 = (760 – 47) x 0.21 = 150 mmHg.

FiO2 = 0.21

PAO2 = 100 mmHg

PaO2 = 90 mmHg

SaO2 – O2 saturation derived from arterialised cap. Blood.

SpO2 – O2 saturation by puls. ox

THUMB RULE: FiO2 x 5 = PaO2

UNWANTED EFFECTS OF O2 THERAPY

IMMEDIATE – Some neonate on hypoxic drive going to apnoea.

LATE - ROP – Persistent PaO2 - main contributary factor

CLD

Free radical damage due to O2 therapy.

HIE

HOME O2 DEPENDANCE AND REHOSPITALISATION

NOSOCOMIAL INFECTION

EFFECTS OF NOT ENOUGH OXYGEN

Pulm Vasc. Resistance

Airway Resistance

Risk of SIDS in Infant with CLD

? Limitation in Growth

? Sleep Disorder

O2 – HOW COSTLY IT IS ?

COMMONLY USED – SIZE F CYL. – CAP – 1320 lit.

Refilling cost – Rs. 140.00

5 lit./ min. = 300 lit./ hr. = 4.5 hr. / CYL. = 6 CYL./day = Rs. 800.00 (approx) , without making any profit

PIPED O2 – CYL. USED – CAP – 7100 – 7500 lit.

Refilling cost – Rs. 220.00

Institutions charge – Rs. 400 – 800/day, irrespective

of usage/ day. !

KEY POINTS New born Resus

If O2 not available – Room Air may be enough in 90% cases.

To save life – Do not think of ROP, Short term PaO2 acceptable.

Beyond EMERGENCY period

Strict monitoring of PaO2 necessary.

To Detect ROP Eye exam from 4-6 weeks & 2–4 weekly in<32 wk. < 1250 gm.

Max O2 flow through nasal catheter - do not exceed 3 lit./ min.

O2 hood – initial flow of 7 lit./ min. required.

KEY POINTS….

Keep PaO2 50 – 80 mm. Hg. , SpO2 88 - 95 %

O2 is a DRUG only should be used Documented hypoxia Resp. Distress Cynosis

When prescribing O2 – specify - Dose Device Duration Monitoring

Take care of devices judiciously to prevent – NOS. INFECTION